Backgrounder: How health providers in Canada are working together to treat poverty and improve health

Social and economic factors play a big role in the health of Canadians

Policy makers have known for some time now that social and economic factors have a big influence on our health and on disparities in health across different groups in society. These factors, known as the “social determinants of health,” include the following, but are not limited to: income, social status, education, our social/physical environment, gender and race.

Health providers are broadening their role to recognize and address the social determinants of health

These less traditional data sources can also potentially be used to inform larger choices with respect to health policy and the design of our healthcare services, as well as to drive innovation to improve healthcare outcomes and reduce healthcare costs.

The CFPC is dedicated to supporting the role of the socially accountable family physician…Family medicine training helps to prepare family physicians to identify and address the health and social determinants of health impacts stemming from family violence and child maltreatment.

Asking the right questions

Healthcare providers routinely screen patients and intervene for poor diet, lack of exercise, substance abuse and high-risk sexual behaviour. While it is clear that poverty is an equally important risk factor requiring screening and intervention, few health organizations and providers routinely collect socio-demographic information and fewer still have that data in individual patient files.

There are a number of reasons for this. When it comes to collecting socio-demographic data, there is not yet a consensus on what questions to ask, how these questions should be worded and how to best survey patients. Doctors are also concerned that patients may misunderstand the purpose for collecting this information and that this could disrupt the doctor-patient relationship.

However, a Toronto pilot study of about 400 patients found that asking questions about socio-demographic characteristics using a tablet was both feasible and acceptable to patients. Patients were willing to answer questions about sensitive subjects including: sexual orientation, gender, housing, religion, race or ethnicity. The highest rate of no response, however, was for questions about income. The study nonetheless suggests that directly linking detailed socio-demographic data to electronic medical records could be used to identify inequalities in real time, develop tailored interventions and more easily evaluate the impact of these interventions on health outcomes.

The Institute of Medicine recommends that doctors collect a mix of core social and behavioural measures and include them in all patient electronic health records. In addition to four measures that are already being collected (race/ethnicity, tobacco use, alcohol use and residential address), it recommends eight more measures. One of these is “financial resource strain.”

In other words, instead of asking patients to reveal their income, the first step to recognizing and treating poverty could be as simple as a health provider asking each patient – Do you ever have difficulty making ends meet at the end of the month?

Building on this,the Centre for Effective Practice has updated and enhanced an original ‘poverty tool’ developed by Dr. Gary Bloch, with support from the Ontario College of Family Physicians. It outlines a plan for primary care providers to screen for poverty, consider the risks and intervene on behalf of their patients.

How health providers are learning to screen their patients for poverty, consider the risks and intervene

According to the ‘poverty tool,’ the first step is for a health provider to ask the question above, about difficulty making ends meet. A positive response would alert the provider to a higher likelihood of certain health problems where poverty is a known risk factor. These include diabetes, cancer, cardiovascular disease and mental illness.

The second step is to verify if the patient belongs to any other high risk groups – e.g., new immigrants, women, Aboriginal peoples and the LGBTQ community. Given an elevated risk level, the provider might then consider medical tests to screen for likely health problems. For example, if an otherwise healthy patient without risk factors for diabetes lives in poverty, a physician could consider ordering a screening test for diabetes. Similarly, if an otherwise low-risk patient presents with chest pain and is also found to live in poverty, this could trigger a more aggressive investigation than might otherwise be ordered.

The third and final step recommended is for the health provider or another health team member to intervene by educating and connecting patients and families to benefits, resources and social services. This could be as simple as asking the patient if they have filed their annual tax return and, if they have not, referring them to a local tax clinic.

In Canada, tax filing is the primary delivery channel for a range of income-boosting benefits that, when accessed, can substantially alleviate financial stress. For example, tax filing can unlock up to $8,000 per year in additional income for a low-income single parent, and at least $1,200 per month for a senior living in poverty. This is why there is a movement afoot amongst health practitioners across the country to encourage patients to file their taxes and seek the social and economic benefits to which they are entitled.

As knowledge of recognizing and treating social determinants of health emerges, health practitioners are moving forward on finding ways to address the issues. By collecting sociodemographic data and applying this information to intervene early and connect patients with resources, health practitioners in Canada are spearheading the treatment of the social determinants of health.

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